Method for Developing Communication Skills in Autism – DHACA: appearance and content validation

ABSTRACT Purpose To validate the appearance and content of the DHACA method to develop communication skills in autism. Methods This qualitative and quantitative validation study included 10 speech-language-hearing judges with expertise in alternative communication. The judges received the communication book, the description of the principles, skills, and strategies in the DHACA method, and a form with items for them to appraise the appearance and content of the method. The validity was calculated with the content validity index. Results The response analysis made it possible to calculate the degree of agreement between judges and develop the new instrument version. The calculation of the content validity index revealed excellent content validity. The judges made suggestions regarding the content of the communication book, texts regarding the participation of communication partners and modeling, using cues, and communicative skills. Conclusion The degree of agreement between judges ensured the validation of the appearance and content of the DHACA method, considering the items alone and the whole instrument. Hence, its use can be recommended for speech-language-hearing clinical practice.


INTRODUCTION
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by changes and impairments in communication and social interaction and restricted and repetitive behavior patterns, interests, and activities, with a wide range of degrees of intensity (1) .
Individuals with ASD have heterogeneous linguistic skills, ranging from the absence of speech or production of few words to the acquisition of more robust verbal skills, though with persistent deficits in situations of functional use, aiming at communication (2) .
They commonly have delayed language acquisition and development, with linguistic impairments in pragmatic, semantic, morphosyntactic, and phonological aspects.They have limited communicative social functions and usually communicate to request or refuse something.The most used communicative functions are related to meeting their needs or protesting (2) .
ASD descriptions also include impairments in shared attention, eye contact, and communicative intention, which influence communication acquisition and development.The more severe the deficit in these skills, the later their communication develops (2) .
The neurotypical language acquisition process evokes various biological and social-pragmatic aspects that enable the development of linguistic skills.Hence, it requires the involvement of sociocognitive skills such as comprehension, shared intentionality, and participation in social-communicative activities with linguistically and symbolically competent people (3) .
Brazilian studies on the effective use of augmentative and alternative communication (AAC) to develop communication in individuals with ASD are still scarce (4) .Most intervention methods used in the country are directly taken from or inspired by protocols developed abroad, which may make them culturally unfeasible or inaccessible to communication partners (4) .
Another gap is the viability of intervention in less structured contexts, as alternative communication programs are usually applied in rather structured settings in which interlocutors do not use verbal cues.Hence, it may be unfeasible to generalize responses to real communication situations (5) .
The DHACA method (a Portuguese acronym that stands for Development of Communication Skills in Autism) 6 is grounded on the social-pragmatic theory or theory of usage-based language acquisition (3) .The author understands that people acquire language through linguistic activities while interacting with others.
The prerequisites to apply the method as a speech-languagehearing intervention include minimum shared attention, good fine motor coordination, normal eye-hand coordination, and the lack of comorbidities such as intellectual or visual disability.Moreover, imitation skills and symbolic play facilitate method implementation.It must be highlighted that this DHACA version is not indicated to children who do not have the above prerequisites, although it may be adapted in future studies.This method has six guiding principles and aims to stimulate five skills.The following are the guiding principles: 1) Using visual cues; 2) Shared attention; 3) Participation of communication partners and Modeling; 4) Using cues; 5) Linguistic development; and 6) Functional communication.The skills are as follows: 1) Initial communicative intention; 2) Requesting with fringe vocabulary lexical expansion; 3) Requesting with lexical and morphosyntactic expansion; 4) Morphosyntactic, lexical, and communicative function expansion; and 5) Dialog.
Given the above, DHACA aims to develop functional communication by using a robust alternative communication system as an alternative to bridge the gap in the national literature, as previously mentioned.Therefore, this study aimed to validate the appearance and content of the DHACA method focusing on its recommendation for use in speech-languagehearing clinical practice.

METHOD
This qualitative-quantitative validation study aimed to validate the appearance and content of the DHACA method to recognize it as reliable and valid to fulfill its purpose.The study was approved by the Human Research Ethics Committee, no.5.831.912.
Ten speech-language-hearing judges were invited for content validation.They were divided equally into two groups: a) professionals with more than 5 years of clinical experience in speech-language-hearing intervention in individuals with autism and who had been using the DHACA method for more than 12 months; and b) professionals with more than 5 years of clinical experience in speech-language-hearing intervention in individuals with autism but who were not using the DHACA method.
After they had been selected, each judge received an invitation letter via e-mail to participate in the research, along with an informed consent form and a form for the validation of the appearance and content of the DHACA method.
DHACA uses a communication book with 66 pictograms on a single page and smaller overlapping tabs with other vocabulary pictograms, organized according to lexical categories, and gradually included in the therapeutic process (6) .These overlapping tabs, organized according to lexical categories, have a single line with 10 pictograms, above which the corresponding words are written.The vocabulary in the method was selected based on the concept of "core words" and "fringe words".Core words are those more frequently used, mainly pronouns, verbs, adjectives and adverbs, which occur often in general interactions.Fringe words are less often used, mainly nouns that tend to be specific to the AAC user's context and interest (7) .
The organization of the core words vocabulary in the DHACA communication book characterizes it as a robust alternative communication system (8) .
The initial version of the method resulted from literature analysis and clinical practice of the speech-language-hearing researchers who developed the method.It was submitted to the judges to analyze the content with the following procedures: a) Presenting the communication book (Appendix A) and describing the principles and skills of the DHACA method and their respective strategies.
b) Analyzing the appearance and content of the communication book by filling out a content analysis form, with which the researchers calculated the content validation index (CVI) (9) and appraised qualitative aspects pointed out by the examiners.
The answer options in the form sent to the judges were as follows: 1 = Not representative; 2 = Little representative; 3 = Representative item; and 4 = Very representative.Besides the score, there was room for possible suggestions, which generated the study's qualitative data.
Each item's relevance score (I-CVI) was calculated by adding the agreement in items checked with "3" or "4" by specialists and dividing it by the total number of answers (9) .
The total instrument's relevance score (T-CVI) was calculated by dividing the total number of items considered relevant by the judges by the total number of items (9) .
Changing or excluding techniques, strategies, and appearance in the book was based on the agreement of at least two judges per item.
After the changes, the material was again presented for the judges' appraisal, which did not lead to any further changes.

RESULTS
The study will first present data on the specialists' responses regarding the appearance of the book -which includes its physical form and visual aspects.In both the 1 st and 2 nd rounds, five judges considered it representative, and the other five considered it very representative.
The interrater agreement rate per item regarding the content of the communication book and principles and skills approached in the method reached values above 78% -i.e., above the minimum to be considered representative -as early as the initial analysis.The summarized analysis of the frequency of judges' responses is shown in Table 1.Likewise, the whole instrument analysis reached 99% of agreement, surpassing the minimum rate to consider it representative (90%).In other words, the instrument was validated even in the first analysis, as the I-CVI and T-CVI agreement rates were above the minimum percentage of 0.78 to be considered representative (Table 2).
It is important to point out that specialists made suggestions for some items that scored "3 = representative item" or "4 = very representative" to improve the method.However, only the items in which at least two judges agreed were changed or excluded from the text.
The excerpt below presents the judges' main suggestions 1. DHACA book, concerning appearance and content "Colored backgrounds in the categories would be more interesting than just the borders"."I miss pictograms for 'my turn' and 'your turn'"."I have never used the demonstrative pronouns 'this' and 'that', so I suggest reviewing these pictograms".

Principle: Participation of communication partners and
modeling "The principle is 'Participation of the communication partner and modeling', but the description focuses on modelingwhereas the partner is responsible for modeling...I think it is important to define 'partner' (an important role in AAC development)".

Principle: Using cues
"I do not always see the need for total physical support to teach a new skill.I prefer the hierarchy of cues from less to greater (verbal, visual, physical).This makes the intervention less invasive and more based on a naturalistic profile".

Principle: Using visual cues
"About the term 'visual cues', would it not be interesting to add, 'participating in an activity together with therapists and another one or two people with complex communication needs to show the use and reach of AAC?In such a strategy, other pairs could illustrate this powerful communication tool". 5. Principle: Functional communication "I suggest including the promotion of communicative functions other than comments and information"."I suggest including an item 'Dialog' -creating a conversation moment: How are you today?Is it going to be sunny or rainy?... etc. Everything that is clearly described gains room".
Based on the suggestions, some changes were made to the appearance and content of the DHACA book and the guiding principles.In appearance, the background of the core vocabulary pictograms was colored according to their parts of speech, instead of having colors only on the borders.As for book content, the demonstrative pronouns "this" and "that" were removed, while "my" and "your" were included".
The researcher made the appropriate changes in the protocol, based on the specialists' analyses in the first round.The revised instrument (second version) was again sent to the specialist judges to assess the material, now changed, continuing the appearance and content validation process.
In the second assessment round, the final version of the instrument reached a high level of agreement between evaluators concerning its appearance and content.
The quantitative analysis of the judges' responses in the reassessment demonstrated that no further changes were needed in the content of the method, thanks to the I-CVI values above 0.78 in all items and 0.92 T-CVI.Reassessment responses, following the reformulation, were more homogeneous, which ensured greater reliability, as seen in Table 2. Furthermore, the few suggestions made in the reassessment were not considered because they addressed issues related to lexical category personalization criteria, which are organized according to the person's needs and demands, as described in the principle "linguistic development".
Since no further changes were needed because of the I-CVI values above 0.78 in all method items, the appearance and content were maintained as defined in this stage.Hence, the DHACA method was considered validated regarding its appearance and content, as it reached a 0.99 T-CVI, fulfilling its purpose.
Thus, the final description of the principles of the DHACA method, with their goals and strategies, is shown in Chart 1, and that of the communicational skills, with their goals and strategies, is shown in Chart 2.

Linguistic development
The method promotes functional communication development by following typical morphosyntactic, lexical, and pragmatic development.Pragmatic skills are developed along with the following communication functions: Initial functions -Communicative intention: using the language to satisfy an immediate desire.Asking for objects, animals, help, actions, people, etc.; responding to others.
-Protesting: disagreeing with or repressing someone else's action, interrupting their speech or action with a desired action.
-Commenting: making comments, giving spontaneous information, showing something, expressing pain, giving opinions, and sharing ideas.
-Expressing feelings: expressing gratitude and feelings.
-Social interaction: greeting, saying goodbye, thanking, apologizing, and showing off.Advanced functions -Reporting: telling a fact or retelling a story.
-Imagination: creating a story or telling a joke.
-Conversation: maintaining a conversation.The main DHACA tool is an AAC book in A4 paper size, with pictograms organized in a grid -A3 paper size can also be used.The vocabulary represented by the pictograms was selected based on the concept of "core words" and "fringe words" (7) .Core words comprise precisely the core ones in the language, mostly verbs, adjectives, adverbs, and pronouns, and rarely nouns, which are very often used in different social contexts.Presenting them as core vocabulary helps the person use various communication functions, such as asking questions, asking for things, refusing, protesting, commenting, and describing.The core vocabulary generally remains in the same place in the communication book to minimize the demands on their memory and motor planning.Altogether 66 pictograms comprise the grid on a single page (Appendix A -Figure 1A).These words, focused on linguistic development, were chosen based on the core word survey described in Franco's thesis (18) .The core vocabulary book page is not personalized.Fringe words comprise nouns and a range of words more related to specific contexts of interest of the AAC user (15) .They are in smaller overlapping pages, forming a single-line grid with 10 pictograms, organized by lexical category (Appendix A -Figure 2A).Some categories may have two or more pages.Personalized lexical categories are gradually included during the therapeutic process, and their vocabulary is selected based on the following criteria: user's preference, such as foods, toys, YouTube channels, etc.; core and fringe word survey (18) , such as qualities, actions, etc.; lexical development, such as colors, numbers, alphabet, geometric shapes, animals, means of transportation, people, places, parts of the body, etc.; pragmatic development: something to say, feelings, etc.; specific needs according to social contexts, such as personal hygiene, school supplies, etc.

Functional communication
The final goal of this method is to promote functional communication in people with ASD -i.e., the ability to receive and convey messages effectively and independently, according to the requirements of the social context, favoring the development of communication skills.This broad definition refers to the whole process, rather than isolated aspects such as speech intelligibility, comprehension, reading, and so forth.It includes all verbal and nonverbal communication modalities and focuses on communicative efficiency and independence, such as appropriate responses to everyday circumstances (19) .Implementing AAC use by individuals with ASD in social interaction requires the planning of interactive situations that promote dialog exchanges between the subject and their interlocutors.Caregivers, health professionals, and classmates must be instructed to stimulate communication with the child in all social settings.1.The therapist should dismiss the single pictograms and bind with a spiral initially one or two tabs of fringe vocabulary pictograms.Each tab has a line with up to 10 pictograms in lexical categories related to the items of preference used in the previous skill.
2. The activity must be planned to trigger in the child the desire to ask for some of their preferred items.3. When the child wants an object but cannot ask for it by pointing independently at it, they must be guided with physical, visual, and/or verbal cues or modeling to point to the pictograms of the sentence: I + WANT + item in one of the fringe vocabulary tabs.4. The therapist begins using the communication book by talking to the child, pointing to pictograms in the core vocabulary page and fringe vocabulary tabs, modeling their communication (i.e., pointing to the pictograms of the words they are speaking), and enabling parents to use the book continuously, as demonstrated in the therapeutic setting.They should also train other relatives and professionals from different contexts.5.The therapist can model by showing the child how to form the desired sentences.6.When the child is able to ask for up to two different items in the fringe vocabulary, pointing at them independently, they can move on to develop the next skill.7. The therapist must instruct caregivers to help the child acquire the skill, demonstrating how to do it with the child and then having the caregiver practice with the child in the therapeutic setting.Thus, they enable parents to use it continuously and train other relatives and professionals from various contexts.The therapist must help caregivers, by providing feedback during practice.

Requesting with lexical and morphosyntactic expansion
The child should be able to form sentences with the pictograms: I + WANT + two pictograms from either the fringe or core vocabulary.Three or more tabs should be added.They should build the sentence in sequence by pointing to the pictograms, possibly accompanied by speech.To advance to the next skill, the child must be able to point to I + WANT + two pictograms from either the fringe or core vocabulary, independently, spontaneously, without cues.
1.The therapist must include fringe vocabulary tabs such as foods, toys, qualities, and places, besides the ones used in the previous skill.
2. The activity must be planned to trigger in the child the desire to ask for preferred items.3. When the child desires an object, action, person, or some help but has difficulty finding the desired pictogram or leafing through the tabs, they can be helped with physical, visual, and/ or verbal cues or modeling to leaf through them independently and point at the pictograms of the sentence: I + WANT + two pictograms from either the fringe or core vocabulary.4. The therapist must use the communication book by speaking to the child, pointing to pictograms in the core vocabulary page and fringe vocabulary tabs, and modeling their communication.
5. The therapist can model by demonstrating to the child how to form the desired sentences.6.When the child is able to ask for up to two items from different tabs, leaf through the tabs independently, and point to the pictograms of the sentence I + WANT + two pictograms from either the fringe or core vocabulary independently, they can move on to develop the next skill.7. The therapist must instruct caregivers to help acquire the skill by demonstrating how to use the book with the child and then asking them to practice with the child in the therapeutic setting.The therapist must help the caregiver with feedback during practice, enabling them to use it continuously and train other relatives and professionals from various contexts.8.The family must be encouraged to further use new words from the core and fringe vocabulary stimulated during the sessions.

Morphosyntactic, lexical, and communicative function expansion
The child should be able to form sentences with three or more words, with different goals: Developing communicative functions: • Informative/interrogative function, asking questions with interrogative pronouns (who, when, which, where, etc.).
• Commenting: making comments, giving spontaneous information, showing something, demonstrating pain, giving opinions, and sharing ideas.

DISCUSSION
The DHACA method was developed based on the scientific knowledge and clinical experience of the speech-language-hearing researchers who developed it throughout their professional history working with AAC in children with autism.
This method uses a robust communication system aiming to bridge the gaps in AAC effectiveness in communication development, the feasibility of implementing it in less structured and more naturalistic contexts, and the possibility of having it clinically reproduced in speech-language-hearing intervention in this population (5) .
The process of validating an intervention method, particularly an AAC one in Brazil, is an innovative factor due to the absence of methods developed for the national context.
The difference in this method is that it is based on the social-pragmatic theory and the linguistic development theory, emphasizing the role of communication partners and the use of various natural contexts.It is a Brazilian method whose linguistic basis is the functional use of the language, from selecting the vocabulary to using communicative functions.Moreover, it considers cultural and individual specificities.
This pioneering Brazilian intervention method describes the skills to be gradually acquired by people with ASD based on linguistic development throughout the intervention, finally aiming at the acquisition of functional communication.It uses a robust, easy-to-handle communication system -a communication book whose core vocabulary comprises pictograms selected based on a bank with high-frequency words (18) and fringe vocabulary.
After the analysis of the judges' agreement in the first assessment, the CVI result validated the appearance and content of the DHACA method (9) .However, relevant qualitative suggestions were made, leading to adjustments that potentialized the appearance and content of the method.It must be emphasized that five judges are professionals with clinical experience in using other AAC intervention methods.Hence, their approval reinforces the validation of the method.
The suggestions included coloring the background of the pictograms in the core vocabulary according to their parts of speech, instead of having only the borders colored.This change reinforces the concept of a semantic color-coding system, which was already used in the method, but only in the borders.Thus, concepts are grouped regarding their grammatical role, facilitating their use and memorization, and helping children develop their grammar.
Another change was the removal of the demonstrative pronouns "this" and "that" and the inclusion of "my" and "your".Studies indicate that the acquisition and use of personal and possessive pronouns are related to the interlocutor's skill in recognizing themselves in their relationship with others and understanding their and the other person's perspective -i.e., the development of social communication skills (20) .Besides these possessive pronouns being quite frequently used as well, this resource stimulates the use of first-person pronouns among people with ASD, who have difficulties in this aspect (21) .
Selecting core words is crucial to obtain good results.Both the selection and organization of vocabulary are essential tasks for successful AAC use.It must provide access to a large vocabulary that is adequate for communication development and organized to make it easier for children to retrieve pictograms (18) .
The suggestion about the content on the participation of communication partners led to highlighting their importance in the skill development process and the use of the resource in various contexts and settings, which agrees with the purpose of the method with a social-pragmatic approach (6) .
It is believed that the initial use of physical cues favors psychomotor development and the acquisition of new skills.Such cues include sensory support with touches, amplified proprioception, and multimodal sensory input (audios combined with visual models to aid independent movements) (22) .Judges also suggested including different communicative functions in the "Functional communication" text.Hence, it included the description of communicative functions in "Linguistic development", classifying them as initial, intermediate, and advanced, and the terminology of the DHACA skills was changed.Robust communication systems allow for exploring and developing various communicative functions along with morphosyntactic, semantic, and pragmatic progress (8) .Furthermore, an adequate selection of core and fringe vocabulary enables children to express themselves according to these various communicative functions (18) .
As for the last skill, its name was changed from narrative to dialog, considering that its goal is to have functional communication -which involves dialog, rather than only narrative communication.
The gaps in scientifically described AAC intervention methods highlight the importance of validating the content and appearance of the DHACA method.Moreover, evidence-based practices in decision-making are essential to increase the quality of therapeutic intervention.
The DHACA method makes way for further AAC intervention studies in people with ASD, helping improve clinical practices regarding language disorders associated with ASD.As for future perspectives, further studies are being planned to advance in other validation stages with other psychometric properties.

CONCLUSION
The study validated the content and appearance of the DHACA method, fulfilling the validation stages defined in the literature.
This innovative method contributes to Brazilian speechlanguage-hearing therapy, considering the importance of using validated instruments and evidence-based practices.

Table 1 .
Distribution of judges according to responses on method representativity (N = 10)

Table 2 .
Content Validation Index of individual items and the whole instrument Caption: CBA = communication book appearance; CBC = communication book content; UVA = using visual aids; SA = expansion; NT = narrative; ICI = initial communicative intention; RFVLE = request with fringe vocabulary lexical expansion; MLCFE = morphosyntactic, lexical, and communicative function expansion; DL = dialog; CVI = Content Validation Index; I-CVI = analyzes each item separately; T-CVI = analyzes the whole instrument

Chart 1. Continued... Chart 2. Description
of skills in the DHACA method, with objectives and strategies (final version).
The therapist must use the communication book to speak to the child, pointing at pictograms in the core vocabulary page or fringe vocabulary tabs, and modeling their communication.5.The therapist can model by demonstrating to the child how to form the desired sentences.6.The therapist can use structured visual resources to help develop the skill.7. When the child is able to form sentences with four or more words with different pragmatic goals, using items from different tabs, and leafing through the tabs independently, then they can move on to develop the next skill.8.The therapist must instruct the caregiver to help the child acquire the skill by demonstrating how to use the book with the child and then having them practice with the child in the therapeutic setting.The therapist must help caregivers with feedback during practice, enabling them to use it continuously, and training other relatives and professionals from various contexts.9.The family must be encouraged to further use new words from the core and fringe vocabulary used to stimulate the child to form new sentences during the sessions.
They should build the sentence in sequence by pointing to the pictograms, possibly accompanied by speech.They must use them with interlocutors in various contexts to begin acquiring the next skill.1.The therapist can include new fringe vocabulary tabs, such as feelings, the notion of time, other verbs, and social greetings, besides the tabs used in the previous skill.2. The activity should be planned to encourage the development of communicative functions with four or more pictograms.3. When the child wants to use any communicative function and has difficulties finding the desired pictogram or leafing through the tabs, they can be helped with physical, visual, and/ or verbal cues or modeling to point at the four pictograms independently.4. *Single pictogram -loose laminated pictogram, separate from the fixed communication board Chart 2. Continued...
The therapist can insert new fringe vocabulary tabs, according to the child's and family's demands in the child's various social and school contexts.2. The activity must be free to encourage dialog using various communicative functions, maintaining conversation, creating, telling, and retelling stories, and reporting facts.3. When the child wants to use any communicative function but has difficulties finding the desired pictogram, they can be helped by rephrasing with modeling.4. The therapist must use the communication book to speak to the child, modeling their communication.5.The therapist can also model by demonstrating to the child how to form the desired sentences.6.The therapist can use structured visual resources to help the child develop the skill.8.The therapist must instruct caregivers to help the child acquire the skill by demonstrating how to use the book with the child and then including the caregiver in the conversation for them to also use the AAC book with the child and the therapist.The therapist must help the caregiver with feedback during practice enabling them to use it continuously and train other relatives and professionals from various contexts.9. Acquiring this skill indicates independence to use the DHACA communication book, beginning the assisted discharge process, and allowing caregivers to insert new tabs as needed.